¡Medicamentos para todos-es un derecho, no un pedido! Medicine for everyone - it's a right, not a demand! With that battle cry, AIDS activists south of the border are coming out of isolation to demand access to life-saving HIV medicines. Over the past year, groups in Central America, South America, and the Caribbean have taken to the streets and the courts, challenging and even suing governments to provide treatment for the region's estimated half-million HIV-positive people. Although some governments have caved in to activist demands, others continue to refuse to provide even the most basic medical services to HIV-positive citizens, and continue to carry out discriminatory policies against them.

"Activists have woken up. Groups of PWAs have united to access medications," says Jairo Pedraza, the U.S.-based delegate to the international board of the UNAIDS program. "This is the hot issue as we speak."

Only 15 percent of people living with HIV in Latin America currently have access to treatment, according to figures cobbled together by international agencies and nongovernmental organizations. Throughout the southern hemisphere, median monthly incomes total a fraction of the price of the three-drug HIV-fighting cocktails, estimated to cost $1,600 a month in the western hemisphere. Many Central and South American governments have no budget at all for HIV treatment.

That includes Honduras, where half of Central America's HIV cases are found. Guatemala and Chile use drug lotteries to provide a lucky few with a limited supply of medicines. Given these gaps in care, private, nonprofit groups have stepped in to pick up the slack by importing and distributing donated drugs or by purchasing discounted drugs bought in bulk on the open market.

In many countries, desperate citizens attempt to cross national borders - Nicaragua to Costa Rica, Bolivia to Argentina - to purchase bootleg HIV meds on the black market or generic knockoffs of dubious quality. But even these medicines are out of the range of most people with HIV in these areas. The luckiest are those with jobs, such as residents of Argentina, Brazil, and Panama, where HIV medicines are paid for by national health, social security, or private insurance programs. But even in these circumstances, there are no guarantees that a government's supply of a given drug will remain consistent. On top of that, AIDS remains a highly stigmatized disease in Latin America, and there are many cases of employers who have fired HIV-positive individuals from their jobs when their serostatus was discovered.

In response, activists have increased their visibility and scored several key victories. Costa Rica started the ball rolling in 1997, when activists sued the government to win a government mandate to provide HIV combination therapy for Costa Ricans with HIV. Today, says Victor Cortez of the Agua Buena Human Rights Association, an AIDS advocacy group in Costa Rica, the national social security office there provides the best HIV services and treatment in all of Central and South America.

In Panama City, an activist group called Probidsida blocked a major thoroughfare for 12 hours after a court ruling denied Panamanians with HIV access to antiretroviral drugs. Earlier this year, the government succumbed to their demands, and a new law now guarantees treatment for anyone with HIV. Mexicans, Colombians, and Brazilians have also won court-mandated HIV care. But beware, warns Pedraza. A seasoned critic, he points out that such court orders are often not carried out. Instead, more effort is needed to make governments comply with such laws.

In El Salvador, AIDS activists have been tenacious in their pursuit of government-funded health care. After exhausting other avenues, a group called ATLACATL appealed to the Inter-American Human Rights Commission in Washington D.C. for help. In late February, the commission ordered the Salvadoran government to supply HIV medicines and care to the 26 Salvadorans who had filed the petition. This decision could spur others in the region to file similar grievances.

In other places, nonprofit AIDS groups have launched treatment initiatives and laid the groundwork for local and national networks that are pushing for access to HIV medicines. Some have organized against insurance companies and governments; others are working to repeal or change patent trade laws that now ban local or generic production of HIV drugs. But when push comes to shove, such organizations are unable to carry the full burden of providing consistent treatment to the large number of people affected. This is especially difficult because many countries lack a health infrastructure, and donated or discounted drug supplies coming from private donors in the United States or Canada, or from drug companies, are often irregular.

Luckily, the picture is beginning to change. Treatment activists and nongovernmental organizations have made progress with international health agencies such as UNAIDS and USAID. Until a year ago, AIDS money for Latin America went only to prevention; now funds have been earmarked for treatment. Looking ahead, the Pan American Health Organization (PAHO), a UN member group, will implement the revolving fund for strategic public health supplies, a new initiative to ensure wider access to medications, goods, and commodities in South and Central America, and the Caribbean. When enough money is raised, the organization will work with an umbrella group, Grupo Technico Horizontal, to negotiate large-scale purchases of HIV medicines from pharmaceutical companies at discounted rates for Latin America.

But to join the revolving fund, a government will have to declare HIV/AIDS a national priority and lay out a comprehensive treatment plan to fight the epidemic, which some have been loath to do. Rafael Mazin, regional adviser on AIDS for PAHO, breaks it down: "We're not talking about billions of dollars. We're talking about millions of dollars, which could save the lives of many people."

The revolving fund will be used only to buy medicines approved by UNAIDS and will allow governments to save money on related costs as well. For example, HIV viral load tests that now cost around $200 per test in the United States will be purchased at lower rates. Right now, most countries have to send viral load tests overseas, which is costly.

Brazil, which has the highest HIV caseload in Latin America, is a critical player in the revolving fund. An estimated 470,000 Brazilians had tested postive for HIV as of late 1997, and as of this past April, around 70,000 were being treated with anti-HIV drugs. PAHO is now deep into negotiations with Brazil's government and drug companies over the issue of access to HIV meds. The way it works, the more drugs ordered, the cheaper the rate will be. Already, such revolving funds have been used to distribute vaccines and will be used to provide tuberculosis and malaria medicines, too.

But right now, PAHO officials can't give a ballpark estimate as to when the fund will be enacted for HIV drugs. That makes activists impatient. After all, as Pedraza points out, every day of delay spells death or disease for someone: "For us living with AIDS, we want to know tomorrow - at 8 a.m."

Several governments in the region, namely Brazil, Venezuela, Argentina, and Panama, provide HIV drugs for their people by negotiating directly with drug companies and haggling over prices on a drug-by-drug basis. Countries that are bound by patent laws can apply directly to the drug company holding the patent for a voluntary license to manufacture and sell a generic version of that drug. Short of that, a compulsory license can be granted allowing a government to either locally manufacture or import a needed drug.

Nations without patent laws can also manufacture generic versions of medicines, and many Latin American countries can legally do so. For example, Brazil produces generic AZT, ddI, ddC, d4T, and ganciclovir (a drug used to treat cytomegalovirus) at lower prices than imported medicines. Activists say that the capacity of a country to locally produce medicines or import cheaper alternative products is crucial in creating competition and lowering market prices. According to Richard Stern, director of Agua Buena in Costa Rica, the underlying problem is that most Central American governments haven't cared enough about AIDS to take such steps. For other diseases, he says, "If the government sends out a [manufacturing] bid to a [local] lab, they'll try to find a way to make it generically."

What will it take for that to happen for HIV? More political action and more bodies on the line, say insiders like Pedraza. "We must put pressure on the government," he says, "because at the end of the day, that's who is responsible for the health care of its citizens."

Cindra Feuer wrote about older woman and HIV in our April/May issue.